While advertisements in and of themselves seem harmless, critics question the influence this money can have on professional groups that are also largely responsible for writing guidelines on treatments and the use of medical devices. ProPublica senior reporters Charlie Ornstein and Tracy Weber investigate this issue in their latest report and join the podcast this week to discuss the implications that financial influence can have on the medical community.

Listen to the podcast and read the full transcript below. You can also see all of Ornstein and Weber's reporting on the issue on the Dollars for Doctors series page.

Ornstein and Weber have worked together since their days at the Los Angeles Times where they won a Pulitzer Prize for their King-Drew series. And they were also Pulitzer finalists here at ProPublica for their coverage of nursing oversight in California. Welcome to the podcast, Charlie and Tracy.

Charlie: Thanks, Mike.

Mike: OK, so why don't we start with you guys explaining what's at play here. Groups like the Heart Rhythm Society get millions of dollars, almost half their budget, from the makers of goods that their doctors may use on patients. Why is that a problem?

Tracy: Well I guess the fear is that all of that money somehow influences the choices of their members, and do they, if they get a lot of money from one company over another company, do they use that device and do they select the devices in the best interests of their patients?

Charlie: I think that patients don't really understand the role that medical societies play in American medicine today. They help write the treatment guidelines that are used by doctors across the country to decide what drugs or devices patients get. They lobby Congress about reimbursement issues, about new products, about research into particular diseases. They're the ones that put up the information on their websites for patients. And there is a concern that when you have that much power and you're sort of hidden from the American public, that there's an opportunity to sort of leverage that to influence an entire specialty as opposed to just a single physician.

Tracy: And there's these sort of medical specialty groups for every kind of specialty, from doctors who do spinal surgeries to hypertension, and each one of those groups is responsible for writing the guidelines for that specialty.

Mike: But don't the doctors universally say, "Well these things don't influence us. We're using what we think are the best tools?"

Charlie: Absolutely. I mean I think doctors genuinely believe that they're doing what's in the best interest of their patients, that they can't be bought from whether it's a lunch or a small trinket or a pen or a notebook, or $1,000, or $5,000, or $10,000. That's a universally held thought. I think that there's sort of a growing body of research that shows that money does have an effect on both perceptions and on outcomes when it comes to clinical research, and so I think that this is an evolving area of science but one that shows that there is some effect of money.

Tracy: And, you know, most physicians will tell you it has no impact on them, but the studies will show you that you want to please someone who's given you something, even if it's something small. And maybe that means you downplay the side effects. Maybe that means you prefer one brand over another if the drugs are roughly equal. Or maybe you go with one device over another.

Mike: Did you find that the Heart Rhythm Society fairly characterizes the procedures its physicians perform?

Charlie: We wanted to do more than just look at the money that the Heart Rhythm Society received. It's one thing to say that a group received money, but it's another to say how does it affect its actions. And you can't necessarily see an effect or a quid pro quo, but what we were able to see was that, in several instances, we found that the society's materials or testimony appear to either omit information about side effects or limitations or downplay them.

Let me give you a couple examples. There are tip sheets on the society's websites that are aimed for patients about implantable cardioverter defibrillators, and these are the devices that shock the heart back to normal rhythm. And it didn't mention anything about risks or about the patients that really weren't studied as part of the clinical trials.

The same thing can be said for another procedure which is known as cardiac ablation, in which a catheter is inserted, and it's designed to sort of destroy the abnormal heart tissue. Again, there really wasn't a discussion about any of the risk or limitations. And drug companies, when they run ads, have to put the side effects in there, but in these cases there was no discussion of the other side other than the benefits.

Mike: As a consumer, is this something that you should ask your doctor about, or as a patient?

Tracy: Well, one thing the Heart Rhythm Society official said is that patient should be talking about the side effects and risks with their physicians. You know there's no way to know whether every physician or every surgeon goes through these side effects and risks with their patients. But patients also look to these medical societies for information, and if you have a category on the website of a society that says, "OK, we're going to give you patient information, and here's one procedure. Why don't you look at this and it'll tell you about the procedure." That should include those side effects and risks so that the patient can be informed on their own.

Mike: You wrote that more than one in five patients who receives the defibrillator doesn't meet the scientific criteria for getting one. Does that really signal inappropriate use?

Charlie: Well, this is really a hot topic now, and the Heart Rhythm Society and its members have been under focus this year in particular with the paper you note which came out in January really shook the field by suggesting that, in fact, more than one in five patients was getting a device inappropriately. The Justice Department is investigating this issue of whether or not doctors are meeting medical criteria. And two of the companies, two of the big sponsors of the Heart Rhythm Society have, in fact, settled allegations of providing kickbacks to physicians in exchange for using their devices.

So I think that there is a huge concern about inappropriate use of these devices. And while this study that you referenced is controversial, it's one I think that has every specialized heart physician on notice right now that they're being looked at.

Tracy: And one of the issues in this is that these devices and these surgeries are hugely expensive. So if, for instance, one of the surgeries cost $35,000 just for the device, and then the surgery itself plus all the attendant costs, and one surgeon or one specialist can do dozens of them a year, we're talking about a lot of money. So when there is a lot of money involved, there's a lot of interest that things are being done appropriately.

Mike: What kind of response are you getting particularly from the medical community?

Charlie: We're getting a lot of responses. And we've solicited people's opinions, and there's really a difference of opinions just as we found in talking to doctors there are many who believe that this is making a mountain out of a molehill, and I think that there are others who think that this is, in fact, a legitimate concern and an acknowledgment that companies would not be spending this level of money on the society at its conference if it wasn't having some benefit.

Tracy: One thing is, we focused on this conference and all of the money that drug and device companies were spending to advertise there and spending a whole bunch of money on like putting their name on a hotel keycard. And what the response we were getting is physicians are saying, yes, we like that these companies have an exhibit where we can see the latest devices and we can feel the latest devices and see how they work and maybe see something that's better than what they're currently using.

But do they really need to have ads on the carpet, and ads on the bus, and ads on the headrests on the bus, and in our room at night, and what benefit does that bring to that?

Mike: And at some level it's subconsciously probably does have some influence. I mean, that's the whole point of advertising.

Charlie: Yes, although the head of the American College of Cardiology said he doesn't buy a soft drink because of an ad. He buys it because he likes it. I think that one of the tenets of the advertising industry is you wouldn't spend the money on advertising if it wasn't moving the needle.

Mike: There was a comment posted by a Doctor Ye, who said that the series was highly relevant, but it misses the essential role of industry money in funding research and development. Ye said without funding support there's also a real risk that good and cost effective treatments will not be widely disseminated. How do you respond to that?

Tracy: Well one thing I think is sort of interesting about that, because the society officials also made that point, individually doctors are funded to do research, and institutions receive money from the pharmaceutical and device industries to do research. But these societies don't do research on their own, so when they're getting this money from the drug and device companies, it's supporting maybe educational things, fellowships. You know they're using the money in a variety of ways. But it is not to develop new products. So I think that he doesn't quite understand how the money goes to benefit the societies.

Charlie: I think the one area that societies do a bit of research is in registries they have for devices where they keep track of when devices are implanted into patients and what the outcomes are. But as Tracy noted, it's not into coming up with the new devices. That's the role of the individual doctor. A lot of the money that societies spend is on awareness, and that's something that you hear the society officials say is they need this money to have awareness campaigns. For the purpose of electrophysiologists, they make the point that there's a big difference between a heart attack and a sudden cardiac death, one being something akin to a plumbing problem of the heart, the other being an electrical problem and how you need in some cases a plumber and in some cases an electrician, and most Americans don't know that. But if it leads to overuse of products, that's a question I think people need to ask.

Mike: OK, I guess the last question is sort of, why is this a ProPublica story?"

Tracy: Well Charlie and I have spent quite a long time. We started out taking a look at the relationships between pharmaceutical companies and physicians, and we've been broadening that to take a look at the relationships between pharmaceutical and device companies and medicine as a whole. And this sort of came out of our look at how much money were physicians getting from drug companies, and what kinds of physicians were getting this money from drug companies, and what kind of impact does this have on the choices that physicians make?

Charlie: There's been a lot of articles focused on sort of this issue on an academic level, but what we've tried to do with our coverage -- both our initial piece about individual doctors and this piece about medical societies -- is bring actual specific facts to the table. And so folks aren't discussing it just in an abstract way, but they're actually looking at the details of how much each group has received. We've put those on our website in a really easy to read search way both for doctors and for medical societies. And in this case we also looked at what the Heart Rhythm Society said which took it to a different level as well.

Tracy: And we also noted that the money comes into these societies, but then their board members are individually getting sponsorships for speaking, for consulting, for research. Some of them have stock. And so in many cases not only is the organization getting money, but many of its board members, many of the folks in decision making positions, they have subcommittees that do education, subcommittees that appoint people to guideline committees to decide what treatments should be used.

And many of those people are also separately getting money, and it's to sort of lay out there what are the conflicts and what are the possible ramifications of that?

Mike: OK. Well, Charlie and Tracy, thank you both very much for joining us.

Tracy:: Thanks.

Charlie:: Thanks, Mike.

Mike: That was Charles Ornstein and Tracy Weber. You can see all of the stories and graphics in their new series at ProPublica.org/docdollars. And look for the sound slides of some photos of the recent Heart Rhythm Society convention meeting as well.

And now it's time for our Officials Say the Darndest Things Tumblr quote of the week. "Giving debt relief to people that really need it, that's what foreclosure is." Who said it? JPMorgan Chase CEO Jamie Dimon, giving CNBC his take on what losing your house to foreclosure actually means.

OK. That wraps up this week's podcast. Thanks to Minhee Cho for producing. For ProPublica, I'm Mike Webb. We'll see you soon.

4 comments

How many Americans are getting these devices and treatments as opposed to those in other developed nations? Frankly, the notion that advertising and perks does not influence doctors is ludicrous. Companies wouldn’t spend the money on marketing if they didn’t think it was having an influence.

Just read, Selling Sickness and other books about The Pharmaceutical Companies manufactured diseases, etc. I need that Dollars for Doctors site on every page of Propublica so I can view my doctors extra income. It’s been very helpful. Thank you for all you do!

FDA and the Supreme Court (Riegel v Medtronic 2/2008) treat medical devices far more leniently than pharmaceuticals. Consumer Representatives and Patient Representatives do not have voting rights on FDA advisory panels to clear medical devices. There is no warranty on product but patients with failed devices cannot go to state court because device manufacturers have the entitlement of pre-emption from state court. Direct-to-consumer advertising has spurred hospitals to build state of the art spinal surgery centers and patients to demand hips and knees at younger ages. This is the #1 expenditure of Medicare.